President Barack Obama was right when he said after the Newtown, Conn., massacre that America had not done enough to keep its children safe. He closed his comments by reading the names of the 20 first-graders killed in the slaughter.
Newtown’s story turns up one more child who may have been, in one way, failed by America: The isolated, awkward boy who would become the 20-year-old killer, Adam Lanza. What, precisely, afflicted Lanza is not yet known. His brutal final act, however, suggests he had a mental disorder.
Lanza would hardly be the first troubled young person who, in the absence of a support system beyond, perhaps, an overwhelmed parent, became horrifically violent. To try to prevent the emergence of more young mass killers, the United States needs to not only reform its gun laws but also improve its mental health care system, especially for children.
The statistics are appalling. An estimated 22 percent of children in the U.S. ages 13 to 18 suffer from mental illness severe enough to impair their daily functioning or produce serious distress. Yet only 20 percent of mentally ill children receive treatment.
With the delay between the onset of symptoms and intervention averaging eight to 10 years, treatment may come too late to make a difference or never, with sometimes disastrous consequences for the individual, the family and, in the worst cases, the community.
The public system for dealing with mental health, never adequate to start with, has been whittled down further during the economic slowdown. From 2009 to 2012, $4.3 billion was stripped from spending nationwide, resulting in reduced services and providers and 4,000 fewer psychiatric hospital beds. Access to care is better for patients who have private insurance coverage for mental illness, but they are a minority.
In theory, two important pieces of legislation will improve the situation.
The 2008 Mental Health Parity and Addiction Equity Act requires group health insurance plans that cover mental illness to provide those benefits as liberally as other benefits. Government officials are still working with industry and patient representatives to finalize regulations enabling states to enforce the act. Those talks should be accelerated and the rules promulgated as quickly as possible.
Access to care will also expand under the Affordable Care Act, which requires the inclusion of mental health coverage in insurance plans to be offered by state exchanges by 2014. The parity act will apply to these plans, too.
Still, increasing insurance coverage doesn’t guarantee mentally ill children will get the care they need. Other barriers must also be addressed. One is a shortage of manpower. Fifty-five percent of counties have no practicing psychiatrists, psychologists or social workers.
The shortfall is especially acute among child and adolescent psychiatrists.
With only 7,000 such specialists practicing in the U.S., getting an appointment with one can take months in urban areas and can entail hours of traveling for people in smaller communities.
Pediatric psychiatry requires two years of training beyond the requirements for general psychiatrists. To encourage taking on that extra burden, the Affordable Care Act authorized a $20 million program to repay student loans if doctors work for at least two years in an underserved area.
Funding for the program, however, was excluded from the House and Senate appropriations bills.
This is a minimal investment, given that mental disorders in the young lead to behavior such as substance abuse, crime and dropping out of school that costs the country an estimated $247 billion annually, according to the Institute of Medicine.
Even if mental health professionals are available, parents often don’t understand their children need this kind of help. The American Academy of Pediatrics in 2010 called for pediatricians to screen all patients for mental illness, just as they regularly test for vision and hearing deficiencies.
Yet few doctors follow this guidance, either because it would lengthen office visits or, given the stigma attached to psychological disorders, because it might offend parents.
The U.S. can’t afford to continue treating mental illness as a source of shame best avoided. Pediatricians and school counselors must discuss the topic openly with parents. Neighbors and friends of an unwell child should offer comfort rather than judgment, just as they would for someone with asthma or diabetes.
In such a world, far more children would have a chance to grow into their best selves.
Bloomberg View (Dec.24)